Patent Grant
10206739
The invention relates to electrosurgical devices and methods for the treatment of pain.
Electrosurgical procedures typically rely on the application of high frequency, for example radiofrequency (RF), energy to treat, cut, ablate or coagulate tissue structures such as, for example, neural tissue. The high frequency energy is often delivered to a region of tissue from an energy source such as a generator via an active electrode of a probe that is inserted into a patient's body. The resistance of tissue, located proximate the active electrode of the probe, to the high frequency energy, causes the tissue temperature to rise. If the temperature is increased past a certain tissue-dependent level, referred to as the lesioning temperature, tissue damage will occur, and a lesion will form. Often, the tissue proximate to the probe heats up faster than tissue farther away from the probe, which may limit the size of the lesion.
In addition to limited lesion size, prior art devices typically form lesions with minimal extension distal to the tip of the electrode, as described by Bogduk et al. (Neurosurgery, 20(4):529-535, 1987) and as shown in
Scientific literature published since Bogduk et al's study continue to emphasize the importance of positioning the electrodes parallel to, as opposed to perpendicular to, the target site, since the general structure of probe electrodes, specifically the exposed conductive portion, has not changed significantly since Bogduk et al's study. For example, Lord et al. (Neurosurgery 36(4):732-739, 1995) note that the electrodes must lie parallel to the nerve for the nerve to be incorporated in the radial lesion. In addition, Hooten et al. (Pain Medicine, 6(2):129-138, 2005) also conclude that, due to the characteristics of prior art probes and lesions formed therefrom, the probes should be placed parallel to the course of the target nerve in order to be effective.
A parallel approach may be difficult and time consuming for a user and it would therefore be advantageous to have a device capable of creating a lesion extending further distal to the probe, as well as a method describing a more perpendicular approach than has previously been possible. Thus, methods and devices that overcome some or all of the deficiencies associated with the prior art are desired.
In order that the invention may be readily understood, embodiments of the invention are illustrated by way of examples in the accompanying drawings, in which:
Embodiments of the invention described herein provide devices, systems, and methods which address some or all of the deficiencies of the current state of the art as described above. For example, in one broad aspect, embodiments of a device of the present invention may comprise an elongate member having one or more electrically insulated portions, and a distal face comprising one or more electrically exposed conductive portions for delivering energy substantially distal to the elongate member. At least one of the one or more electrically insulated portions may extend from a proximal region of the elongate member to the distal face.
In another broad aspect, a method is provided for creating a lesion at a target site within a body of a human or animal using an electrosurgical device. The method may comprise the steps of: inserting the electrosurgical device into the body such that the electrosurgical device is generally upstanding relative to the target site; and delivering energy from an energy source solely through a distal face of the electrosurgical device to the target site for creating the lesion at the target site.
In another broad aspect, embodiments of a device of the present invention may comprise a cannula having one or more electrically insulated portions and one or more electrically exposed conductive portions. The cannula may define one or more lumens. The device may further comprise an internally cooled elongate member sized to be disposed within one of the one or more lumens of the cannula, such that at least a portion of the elongate member is in electrical and thermal contact with the cannula.
In another broad aspect, embodiments of a device of the present invention may comprise a sterilizable electrosurgical device. In some embodiments, the device may comprise a sterilizable elongate member comprising one or more electrically insulated portions and one or more electrically exposed conductive portions. The elongate member may define at least one lumen. The device may further comprise at least one sterilizable connector at a proximal region of the elongate member. In another embodiment, the device may comprise a sterilizable elongate member having one or more electrically insulated portions and one or more electrically exposed conductive portions. The elongate member may define at least one lumen. The device may further comprise one or more sterilizable tubes associated with a proximal region of the elongate member, and at least one of the one or more sterilizable tubes may be operatively connected to the at least one lumen for delivering a fluid to the at least one lumen.
In another broad aspect, embodiments of the present invention may provide a method of delivering energy to a patient's body. The method may comprise the steps of: inserting at least one electrosurgical device into a patient's body, wherein the device has a longitudinal axis; positioning the at least one electrosurgical device such that the longitudinal axis of the device is generally upstanding relative to a target site within the patient's body; and delivering energy from the device to the target site, wherein the at least one electrosurgical device is cooled.
In another broad aspect, embodiments of the present invention may comprise a method of treating pain. The method may comprise, in any order, the steps of: introducing at least one electrosurgical device into a region of a patient's body; cooling the at least one electrosurgical device; and delivering energy through the at least one electrosurgical device to at least one target site within the region of a patient's body to affect at least one neural structure.
In another broad aspect, embodiments of the present invention may comprise a method for creating a lesion in order to affect at least one neural structure at a target site within a patient's body. The method may comprise, in any order, the steps of: determining one or more parameters of a lesion, such that the lesion created in accordance with the one or more parameters will affect the at least one neural structure; determining a length of an electrically exposed conductive portion of an electrosurgical device based on at least one of the one or more parameters of the lesion; inserting an electrosurgical device comprising an electrically exposed conductive portion having the determined length into the patient's body; and delivering energy to the target site through the electrosurgical device.
With specific reference now to the drawings in detail, it is stressed that the particulars shown are by way of example and for purposes of illustrative discussion of certain embodiments of the present invention only, and are presented in the cause of providing what is believed to be the most useful and readily understood description of the principles and conceptual aspects of the invention. In this regard, no attempt is made to show structural details of the invention in more detail than is necessary for a fundamental understanding of the invention, the description taken with the drawings making apparent to those skilled in the art how the several forms of the invention may be embodied in practice.
Before explaining at least one embodiment of the invention in detail, it is to be understood that the invention is not limited in its application to the details of construction and the arrangement of the components set forth in the following description or illustrated in the drawings. The invention is capable of other embodiments or of being practiced or carried out in various ways. Also, it is to be understood that the phraseology and terminology employed herein is for the purpose of description and should not be regarded as limiting.
With reference first to
In some embodiments, probe 100 may define at least one lumen 124, as will be described hereinbelow. Furthermore, in some embodiments, either or both of distal end 106 and proximal end 110 may define at least one aperture, which may be in communication with lumen 124. In other embodiments, probe 100 may not define a lumen, and therefore may be described as substantially solid.
As shown in the embodiment of
In some embodiments, for example as shown in
The size and shape of probe 100 may vary depending on the application, and the invention is not limited in this regard. For example, in some embodiments, the transverse cross sectional shape of probe 100 may be substantially circular. In other embodiments, the cross-sectional shape may be substantially polygonal, elliptical, or any other desired shape. In some embodiments, the length from distal end 106 to proximal end 110 of probe 100 may be between about 5 cm and about 40 cm and the outer diameter of shaft 122 may be between about 0.65 mm and about 2.00 mm (between about 20 AWG and about 12 AWG). In one specific example, the length of the probe may be about 7.5 cm, the outer diameter may be about 1.5 mm, and the transverse cross-sectional shape may be substantially circular. The shape of distal end 106 may vary depending on the application. Possible shapes include, but are not limited to, blunt, rounded, sharp, and beveled.
Probe 100 may be rigid or flexible and may be straight, bent or angled at one or more points along its length. As used herein, the term ‘bent’ refers to any region of non-linearity or any deviation from a longitudinal axis, gradual or abrupt, and at any angle. In embodiments wherein probe 100 is bent, the bend may be at various locations along probe 100, for example in distal region 104. Furthermore, the bend may be of a variety of degrees and lengths. For example, the bend may traverse about 25° of a circle, and occur over a length of about 5 mm. Furthermore, probe 100 may comprise a plurality of bends, which may or may not be in the same plane. For example, in some embodiments, probe 100 may be bent such that it is helical or ‘corkscrew’ shaped. In some embodiments, probe 100 may be structured such that its shape may be modified by a user before or during the course of a procedure. More specifically, the shape of distal region 104, for example, may be modified such that it may change from a straight to a bent configuration using an actuating mechanism. This may aid in accessing difficult to reach sites within the body. This may be accomplished by a variety of means, for example, probe 100 may comprise at least one active shape control mechanism, including but not limited to one or more pull-wires, a hydraulic or piezoelectric device, or another actuating mechanism.
In one embodiment, electrically insulated portion 116 may be formed by coating a portion of shaft 122 with an electrically insulative coating, covering, or sheathing. In other words, probe 100 may comprise electrically insulative material disposed on the surface of the elongate member. For example, in one embodiment shaft 122 of probe 100 may be fabricated from a biocompatible metal or alloy, for example stainless steel, which may be overlaid in part by an insulating coating, for example polytetrafluoroethylene (PTFE). In other embodiments, shaft 122 may be fabricated from another metal, such as nitinol or titanium, and/or another electrically insulating material, including but not limited to polyethylene terephthalate (PET), may be disposed thereon. In other embodiments, other metals or electrically insulating materials may be used, and the invention is not limited in this regard. Furthermore, the insulating material may be semi-porous, to allow for some leakage of current through the insulating material. In some embodiments, the material may also be a thermal insulator as well. In some embodiments, different insulating materials can be used for different portions of probe 100. The uncoated portion of the distal region of shaft 122 may serve as an conductive portion 118. The insulating coating may be applied to a portion of shaft 122 by dip-coating, spraying or heat shrinking, for example.
In another embodiment, the shaft 122 of probe 100 may be fabricated from an insulative or non-conductive material and may be furnished with one or more externally applied electrodes 118. In such embodiments, probe 100 may comprise one or more wires that may be attached to electrode(s) 118 at one end, and may run proximally along shaft 122, such that a proximal portion of the wire(s) may be operatively connected to an energy source, thereby supplying energy to electrodes 118. For example, shaft 122 may be fabricated from Radel® plastic, and the externally applied electrodes may be fabricated from stainless steel.
In alternate embodiments, shaft 122 may be manufactured from a combination of materials. For example, the distal region of shaft 122 may be made from a material such as nitinol, such that the shape of the distal region may be altered, and the remainder of shaft 122 may be made from stainless steel, such that the remainder of shaft 122 may be substantially fixed.
In some embodiments, probe 100 may be cooled. In some specific embodiments, probe 100 may be cooled by the internal circulation of a cooling fluid. Such a configuration, whereby a cooling medium does not exit from a distal region 104 of probe 100, may be referred to as an internally-cooled probe. The cooling fluid may be any fluid suitable for removing heat from probe 100 during surgery, for example water. Other examples of cooling fluid include, but are not limited to, liquid nitrogen and saline. Furthermore, the fluid may be at any temperature suitable for removing heat from the probe during surgery, for example between about 0° C. and about 25° C. More specifically, the temperature of the fluid may be at about room temperature (21° C.), about 4° C., or about 0° C., depending on the application.
In addition, the fluid may be delivered or circulated at a wide range of flow-rates, and the invention is not limited in this regard. An appropriate flow-rate may be determined or calculated based on a number of factors, including the conductivity and heat capacity of elongate member 100, the cooling fluid and/or the tissue, the internal structure of the probe, as described hereinbelow, and the desired temperature of distal end 106 of elongate member 100, among other factors. In some embodiments, the fluid may be delivered at between about 10 ml/min and about 30 ml/min.
Several embodiments of the internal structure of a probe cooled by the internal circulation of a cooling fluid are shown in
In another embodiment, as shown in
In embodiments wherein probe 100 is bent, as described hereinabove, internal tubes 130 and/or 131 may be structured to accommodate the bend. For example, in one embodiment, internal tubes 130 and/or 131 may be bent at a similar location and angle as probe 100. In another embodiment, internal tubes 130 and/or 131 may end at a location that is proximal to the location where probe 100 bends. In embodiments wherein the shape of probe 100 is structured to be modified before or during a procedure, internal tubes 130 and/or 131 may be structured such that their shape is also modified along with probe 100.
In alternate embodiments, fluid exiting probe 100 may not be returned to the source of cooling, but may rather be removed to another location, for collection and/or disposal of the fluid.
In some embodiments, a flow impeding structure 314 may be used to restrict the flow of cooling fluid within probe 100. For example, in the embodiment shown in
Means for cooling probe 100 may include, but are not limited to, circulation of a cooling fluid, for example as described above, cooling by a thermoelectric circuit, or chemical cooling by an endothermic reaction. In some embodiments, probe 100 may be cooled by a thermoelectric circuit. For example, probe 100 may partially or fully house a circuit comprising two dissimilar metals or semiconductors, for example P- and N-doped bismuth-telluride, which are joined together at two junctions. When current passes through the circuit, heat may be transferred from one junction to the other. This phenomenon is known as the Peltier Effect. The junction where the heat is transferred from may be located in the distal region of probe 100, and the junction where the heat is transferred to may be located at a proximal region of probe 100 or externally to probe 100. Energy may be provided to the circuit by an external energy source (for example, the same energy source that delivers RF energy to probe 100), an electrical generator or a battery, for example.
In an alternate embodiment, probe 100 may be cooled chemically. For example, probe 100 may comprise two internal tubes, similar to the structure shown in
As mentioned hereinabove, one or more fluids may be delivered from a reservoir to lumen 124 of probe 100 for the purposes of cooling probe 100. The fluid(s) may be delivered to the probe via a number of means, and the invention is not limited in this regard. For example, in one embodiment, the reservoir of fluid may comprise a container, for example an intravenous (IV) bag 614, which is elevated above the patient. Tubing 616, for example clear plastic flexible tubing, may be used to connect the reservoir to an inlet in probe 100. A valve 618 may be placed at the junction of the container and the tubing (or at some other location between the container and the probe), such that when the valve is opened, gravity may cause fluid to flow towards probe 100. After circulation within probe 100, fluid may exit probe 100 via tubing similar to tubing 312, which may drain into another reservoir, for example a second IV bag. In another embodiment, at least one pump may be used to deliver fluid to the probe. For example, at least one peristaltic pump 610, shown in
Tubing 310 and 312 may be made from a variety of materials. For example, tubing 310, 312, may be fabricated from a flexible plastic material, such as Tygon (trademark), polyvinylchloride (PVC) or polycarbonate. In some embodiments, tubing 310 and 312 may comprise markings or other means of identification, such that the inflow tubing is distinguishable from the outflow tubing. Further details regarding this concept are disclosed in U.S. patent application Ser. No. 11/105,527 (filed on Apr. 14, 2005), previously incorporated herein by reference.
In some embodiments, elongate member 100 may be sterilizable. In these embodiments tubing 310 and 312 may or may not be sterilizable as well. The elongate member may be capable of being sterilized by, for example, steam, ethylene oxide, or radiation sterilization without risk of material degradation or discoloration. In order for elongate member 100 to be sterilizable, elongate member 100 may be made from sterilizable materials, for example, shaft 122 may be made from stainless steel and the electrically insulative coating may be made from PTFE. In embodiments wherein tubing 310 and 312 are sterilizable, tubing 310 and 312 may be made from medical/surgical Tygon tubing. In other embodiments, tubing 310 and 312 may be detachable from probe 100, and therefore may not be required to be sterilizable. In this embodiment, probe 100 may comprise at least one connector, which may be sterilizable, for connecting probe 100 to tubing 310 and 312, or another fluid source. The at least one connector may comprise means for securing a fluid source to the elongate member, for example a luer lock, which may fit between tubing 310 and 312 and lumen 124, thus allowing for fluid communication between tubing 310 and 312 and lumen 124. In one embodiment, elongate member 100 may comprise two sterilizable connectors, one of which may couple a tube for inflowing fluid to one of lumen 124 and internal tube 130, and the other of which may couple a tube for outflowing fluid to the other of lumen 124 and internal tube 130.
In some embodiments, probe 100 may comprise at least one temperature sensing device 112, i.e. a temperature sensor. Temperature sensing device 112 may be any means for sensing and/or measuring temperature, including, but not limited to, a thermocouple, a thermistor, an optical fluorescence sensor, and a resistance thermometer. In some embodiments, temperature sensing device 112 may be positioned at the distal region of probe 100, for example at distal end 106. As shown in the embodiments of
In an alternate embodiment, temperature sensing device 112 may be located within lumen 124 of probe 100 so as to measure the temperature of a cooling fluid. By monitoring the change in temperature of the cooling fluid, which relates to the amount of heat being drawn away from the probe, the temperature of the tissue located adjacent conductive portion 118 may be determined.
In another embodiment, probe 100 may comprise an extendible remote temperature sensing element which may be deployed from probe 100. An extendible temperature sensing device 112 may allow monitoring of the temperature within tissues located remotely from the surface of conductive portion 118. The extendible temperature sensing device 112 may further be steerable so that its position may be changed during a procedure to obtain temperature measurements from a variety of tissue regions.
In some embodiments, probe 100 may comprise means for operatively connecting temperature sensing device 112 to an external device. In some embodiments, such a device may be a display or screen, such that the temperature measured by the temperature sensing device may be viewed by a user. In other embodiments, the external device may be an electrical generator, such that temperature feedback may be provided to the electrical generator. Means for operatively connecting temperature sensing device 112 to an external device may comprise an insulated wire 128, which may extend proximally from temperature sensing device 112, through a lumen of probe 100, and out of probe 100 through proximal end 110. Wire 128 may be any temperature or electrical conductor capable of operatively connecting temperature sensing device 112 to an external device. Alternatively, temperature sensing device 112 may be operatively connected to an external device via a wireless connecting means, including, for example, infrared or Bluetooth (trademark). Further details regarding temperature sensing devices may be found in U.S. Patent Application Publication 2005/0177209 (published on Aug. 11, 2005), incorporated herein by reference.
In some embodiments, electrosurgical instrument or device 100 may comprise a sensor for measuring impedance. As the impedance of a tissue may be a characterizing factor, measuring the impedance of tissue proximal to the probe can help confirm placement within a desired tissue type. In some embodiments, probe 100 may be structured to measure the electrical impedance between, for example, two points on probe 100 or between a point on conductive portion 118 and a point on an auxiliary device such as a cannula or a grounding pad. Further details regarding impedance measuring means may be found in U.S. Patent Application Publication 2005/0177209 (published on Aug. 11, 2005), incorporated herein by reference.
In some embodiments, probe 100 may comprise a sensor for measuring pressure. The means of measuring pressure may comprise a lumen in fluid communication with fluid in a patient's body as well as with a pressure transducer to record the pressure measurements. In other embodiments, the pressure sensor may comprise a pressure transducer disposed at a desired location on probe 100.
As mentioned above with respect to the temperature sensing device, probe 100 may comprise means for operatively connecting any impedance or pressure measuring means to an external device. For example, a pressure transducer may be electrically coupled to a wire located within probe 100, which wire may be further electrically coupled to an external device to transmit a signal from the pressure transducer to the external device.
In some embodiments, probe 100 may comprise means for enhancing the visualization thereof, for example when viewed under fluoroscopic imaging or another imaging modality. Such means may be a visible marker, a radiopaque marker or markers for use with magnetic resonance imaging or ultrasound, for example. Further details regarding enhanced visualization are disclosed in U.S. patent application Ser. No. 10,382,836 (filed on Mar. 7, 2003), and Ser. No. 11/079,318 (filed on Mar. 15, 2005), both of which are incorporated herein by reference.
In some embodiments, hub 114 may have markings to indicate, for example, the direction/orientation of a bend or curve of probe 100 or the location of an aperture or a temperature or pressure sensing device on or within probe 100. These markings may be visual indicators, or tactile indicators, which may be textured or raised so that the user may see or feel the markings while manipulating probe 100.
As has already been mentioned above, in some embodiments probe 100 may be furnished with at least one aperture, which may be in fluid communication with lumen 124. Such an aperture may be a lateral port defined by a side wall of probe 100 providing an outlet for the delivery of cooling fluid, anesthetic, or any other treatment compound to a target treatment site in a body. Alternatively, the at least one aperture may be located at the distal end of probe 100.
In some embodiments, a proximal end of probe 100 may comprise a strain relief, which may additionally comprise a grip running from the proximal end to the distal end of the strain relief. A strain relief may be, for example, a soft flexible bend relief able to support any cable or tubing exiting the proximal end of probe 100.
As mentioned hereinabove, the size and/or geometry of electrically insulating region 116 and conductive portion 118 may differ depending on the specific application. As disclosed in U.S. Provisional Patent Application 60/743,511 (Filed on Mar. 16, 2006), and 60/595,559 (Filed on Jul. 14, 2005), previously incorporated herein by reference, when sufficient energy is delivered from an energy source through an active electrode to a tissue of a patient's body, a lesion may form in the tissue wherein the size, shape, and location of the lesion are at least partially dependent on the size and/or geometry of the active electrode.
Exemplary embodiments of probes 100 having a conductive portion 118 of various geometries, and being of between about 16 AWG and about 19 AWG, and examples of lesions 502 that may be formed therefrom are illustrated in
Referring now to
In some embodiments, the electrically insulated portion may extend substantially from the proximal region of probe 100 to the distal end of probe 100. For example, the electrically insulated portion may terminate at the distal face of the probe such that distal face 107 of probe 100 comprises at least one electrically exposed conductive portion. As will be apparent to the person skilled in the art, depending upon the geometry of the probe, the electrically insulated portion may terminate slightly proximal to the distal face so long as the energy delivery remains substantially distal. In some embodiments, a portion of distal face 107 may comprise at least one conductive portion 1118 as shown, for example, in
In some embodiments, probe 100 may be structured to have a conductive portion of a fixed size. In other embodiments, the size of the conductive portion may be adjustable. For example, in one embodiment, wherein probe 100 comprises a conductive shaft with an electrically insulative sheath or coating disposed thereon, the electrically insulative sheath may be structured such that it may be slid or otherwise moved distally or proximally along the shaft. Thus, when the electrically insulative sheath is moved proximally along the shaft, the electrically exposed portion, or active electrode, would become longer. When the electrically insulative coating is moved distally on the shaft, the active electrode would become shorter. As mentioned above, altering the length of the active electrode may affect the geometry of a lesion formed therefrom. In some embodiments, the length of the active electrode may be modified before, during or after a treatment procedure while, in other embodiments, the length of the active electrode may not be modified during the actual course of the procedure. For example, in one such embodiment, the probe may have a safety mechanism, for example a stopping means such as a clamp, to prevent movement of an insulative sheath during the course of a treatment procedure.
In another alternate embodiment of the present invention, a treatment apparatus may comprise a cannula, in addition to a probe. The cannula may be used to deliver energy to the patient's body, as will presently be described, and/or the cannula may be used to facilitate insertion of the probe, as will be described hereinbelow. In embodiments wherein the cannula is used to deliver energy, the cannula may comprise at least one electrically exposed conductive portion and at least one electrically insulated portion. In some embodiments, the body of the cannula may be constructed from a conductive material, which is at least partially overlain with an insulating sheath or coating, defining the insulating region; however, in some embodiments, the cannula may be constructed from an insulating material with one or more conductive bodies or electrodes applied externally. The distal end of the cannula may be pointed or sharp. For example, the distal end of the cannula may comprise a bevel. In one embodiment, the at least one electrically insulated portion may extend from the proximal region of the cannula to the distal end of the cannula, such that the distal face of the cannula comprises at least one exposed conductive portion. In embodiments comprising a bevel, the at least one exposed conductive portion may comprise the bevel. In alternate embodiments, the exposed conductive portion may, alternatively or in addition, be located on a side of the cannula. In some embodiments, the electrical insulation may extend to the heel of the bevel of the cannula while in others the insulation may end further proximally along the cannula.
In some embodiments, the cannula is straight, whereas in some other embodiments the cannula may be bent. For example, in some such embodiments, the cannula may have about a 5 to about a 20 degree bend in the distal region of the cannula. In some embodiments, the cannula may be between about 16 and about 18 AWG, between about 75 and about 150 mm in length, with the electrically exposed conductive portion about 2 mm to 6 mm in length. In these embodiments, the probe may be structured to be disposed within the lumen of the cannula, and to be in electrical contact with the cannula when fully disposed within the cannula.
The probe may comprise an electrically conductive elongated shaft, a connecting means for connecting to an energy source, and a connecting means for connecting to a cooling supply, for example as described herein above. Thus, when energy is supplied by an energy source to the probe, the energy flows along a conductive portion of the cannula and is delivered to the target treatment site, traveling through the tissue or body to a reference or return electrode. In such embodiments, the shaft of the probe may be electrically conductive and exposed along substantially the entire length of the probe. In other words, a probe used in such an embodiment in conjunction with a cannula may not comprise an electrically insulative coating as described above.
In some embodiments, the distal end of the probe may be substantially flush with the distal end of the cannula when fully disposed in the cannula. In other embodiments, the distal end of the probe may extend distally from the distal end of the cannula when fully disposed in the cannula. In other embodiments, the distal end of the elongate member may be recessed proximally from the distal end of the cannula when fully disposed in the cannula. As used herein, the phrase ‘fully disposed’ refers to a first member being substantially fully received within a second member such that, under normal use, it is not intended to be inserted into the second member any further.
The probe and cannula may be structured such that when the probe is fully disposed within the cannula, at least a portion of the probe is electrical and/or thermal contact with at least a portion of the cannula, such that thermal and/or electrical energy may be delivered from the probe to the cannula. This may be accomplished by flushing the cannula with a fluid such as saline prior to inserting the probe, such that a layer of fluid remains between at least a portion of the probe and cannula. The saline may then serve to conduct electricity and/or heat between the probe and the cannula. Alternatively, the probe and cannula may be structured such that they are in physical contact when the probe is fully disposed within the cannula, thereby also being in electrical and thermal contact. In a further embodiment, a portion of the probe may be in thermal contact with the conductive portion of the cannula. This may be beneficial in that the cooling of the probe would allow for the conductive portion of the cannula to be cooled. The probe may be cooled by a variety of methods, as described hereinabove.
In certain embodiments, it may be desired to utilize a probe of this embodiment with preexisting cannulae. Thus, it may be desirable to provide a probe within a certain range of outer diameters, for example between about 24 AWG and about 31 AWG. A probe of this embodiment may therefore comprise a single internal lumen, for example as shown in
Embodiments comprising a cooled probe within a cannula may be advantageous in that pre-existing cannulae may be used in conjunction with such embodiments of a cooled probe. Examples of such cannulae include the Baylis Pain Management Radiofrequency Cannula of Baylis Medical Company Inc. (Montreal, Canada). Thus, these probe embodiments may allow for use of a cannula that is similar to those currently in use and familiar to practitioners, but which can be used to create larger lesions than presently possible due to the cooling supplied to the probe disposed within the cannula. In addition, practitioners may be familiar with a procedure involving positioning the distal region of a cannula at a target site, positioning a probe within the cannula, and delivering energy from the probe to the cannula, and from the cannula to the target site. Thus, a cooled probe of this embodiment, sized to be disposed within a cannula, would allow practitioners to follow a normal procedure with the added benefit of cooling, similar to what they have previously practiced using a similar cannula though without cooling.
With reference now to
The introducer apparatus may aid in inserting probe 100 into a patient's body. The introducer apparatus may comprise a hollow elongate introducer or cannula 604 and an obturator 606. In this embodiment, as mentioned hereinabove, cannula 604 may be useful for facilitating insertion of the device into the patient's body. For example, cannula 604 and/or obturator 606 may be substantially stiff or rigid, such that the introducer apparatus may assist in piercing skin or other body tissues. Obturator 606 may be structured to cooperatively engage with cannula 604. In other words, obturator 606 may be sized to fit within the lumen of cannula 604 and may comprise means for securing obturator 606 to cannula 604. In one embodiment, when obturator 606 is fully disposed within cannula 604, obturator 606 sufficiently occludes the lumen of cannula 604 such that tissue is prevented from entering the lumen when the introducer apparatus is inserted into the body. In some embodiments the distal end of obturator 606 may be sharp or pointed. In these embodiments, the distal end of obturator 606 may be conical, beveled, or, more specifically, tri-beveled. The lengths of obturator 606 and cannula 604 may vary depending on the application. In one embodiment, cannula 604 may be sized such that its distal end can reach the target tissue within the body while the proximal end remains outside of the body. In some embodiments, cannula 604 may be between about 5.5 inches (13.97 cm) and about 7.5 inches (19.05 cm) in length, and obturator 606 may be between about 5.5 inches (13.97 cm) and about 7.5 inches (19.05 cm) in length. More specifically, cannula 604 may be about 6.4 inches (16.26 cm) in length, and obturator 606 may be about 6.6 inches (16.76 cm) in length. Obturator 606 may be slightly longer than cannula 604, so that the distal end of obturator 606 may protrude from cannula 604 when fully disposed. In some embodiments, obturator 606 may be substantially longer than cannula 604, and may be visible under fluoroscopy, such that it may aid in visualizing the location of lesion formation when a cooled probe is used. Further details regarding this embodiment are disclosed in U.S. Provisional Patent Application 60/744,518 (filed on Apr. 10, 2006), incorporated herein by reference. The lumen of cannula 604 may also be sized to accommodate the diameter of probe 100, while remaining as small as possible in order to limit the invasiveness of the procedure. In a specific embodiment, the proximal regions of cannula 604 and obturator 606 are structured to be locked together with a hub or lock.
In one embodiment, cannula 604 and obturator 606 may be made from stainless steel. In other embodiments, cannula 604, obturator 606, or both may be made from other materials, such as nickel-titanium alloys for example. Furthermore, in some embodiments, obturator 606 may comprise a means for connecting obturator 606 to generator 608, for example a wire or cable. In such embodiments, obturator 606 may be operable to measure the impedance of tissue as the introducer apparatus is inserted into the patient's body. In addition or alternatively, obturator 606 may be operable to deliver stimulation energy to a target tissue site, as described further herein below.
In some embodiments, probe 100 may be structured to be operatively connected to an energy source 608, for example a generator 608. Connecting means 612 for connecting probe 100 to generator 608 may comprise any component, device, or apparatus operable to make one or more electrical connections, for example an insulated wire or cable. In one embodiment, connecting means 612 may comprise an electrical cable terminating at hub 114 as well as a connector at a proximal end thereof. The connector may be operable to couple to energy source 608 directly or indirectly, for example via an intermediate cable. At least one wire or other electrical conductor associated with cable 612 may be coupled to a conductive portion of shaft 122, for example by a crimp or solder connection, in order to supply energy from energy source 608 to shaft 122. In one specific embodiment, a 4-pin medical connector may be used to connect cable 612 to an intermediate cable (not shown), which may be further attached to a 14-pin connector capable of being automatically identified when connected to generator 608.
Generator 608 may produce various types of energy, for example microwave, ultrasonic, optical, or radio-frequency electrical energy. In some embodiments, generator 608 may produce radiofrequency electrical current, having a frequency of between about 10 kHz and about 1000 kHz, at a power of between about 1 W and about 50 W. In some embodiments, generator 608 may comprise a display means incorporated therein. The display means may be operable to display various aspects of a treatment procedure, including but not limited to any parameters that are relevant to a treatment procedure, such as temperature, power or impedance, and errors or warnings related to a treatment procedure. Alternatively, generator 608 may comprise means for transmitting a signal to an external display. In one embodiment, generator 608 may be operable to communicate with one or more devices, for example with one or more probes 100 and/or one or more source of cooling, for example pumps 610. Such communication may be unidirectional or bidirectional depending on the devices used and the procedure performed. An example of an RF generator that may be used as part of a system of the present invention is the Pain Management Generator (PMG) of Baylis Medical Company Inc. (Montreal, QC, Canada). Further details regarding embodiments of energy sources are disclosed in U.S. patent application Ser. No. 11/105,527 (filed on Apr. 14, 2005) and Ser. No. 10/122,413 (filed on Apr. 16, 2002), both of which are previously incorporated herein by reference.
As an example of communication between generator 608 and other devices in a system of the present invention, generator 608 may receive temperature measurements from one or more temperature sensing devices 112. Based on the temperature measurements, generator 608 may perform some action, such as modulating the power that is sent to the probe(s). For example, power to the probe(s) could be increased when a temperature measurement is low or decreased when a measurement is high, relative to a predefined threshold level. If more than one probe is used, the generator may be operable to independently control the power sent to each probe depending on the individual temperature measurements received from the temperature sensing devices associated with each probe. In some cases, generator 608 may terminate power to one or more probe(s) 100. Thus, in some embodiments, generator 608 may receive a signal (e.g. temperature measurement) from one or more probe(s), determine the appropriate action, and send a signal (e.g. decreased or increased power) back to one or more probe(s).
Alternatively, if one or more cooling means, i.e. sources of cooling, comprises one or more pumps 610, for example peristaltic pumps, the one or more pumps 610 may communicate a fluid flow rate to generator 608 and may receive communications from generator 608 instructing pump(s) 610 to modulate this flow rate depending, for example, on temperature measurements received by generator 608. In some embodiments, the pump(s) 610 may respond to generator 608 by changing the flow rate or by turning off for a period of time. The pumps may be turned off in order to allow the temperature of the tissue surrounding probe 100 to reach equilibrium, thereby allowing a more precise determination of the surrounding tissue temperature to be made. In addition, when using more than one probe 100, in embodiments where the generator does not control each of the probes independently, the average temperature or a maximum temperature in the temperature sensing elements associated with probe(s) 100 may be used to control the cooling means.
As mentioned hereinabove, in some embodiments, one or more peristaltic pumps 610 may be used to supply a cooling fluid to and return a cooling fluid from probe(s) 100. In other embodiments, other types of pumps may be used. Examples include, but are not limited to, a centrifugal pump or a piston pump. As mentioned above with respect to temperature control, controlling the delivery of a cooling fluid, or other cooling means, may be performed for each probe independently or the cooling may be controlled based on an average temperature measurement or a measurement recorded from one probe, for example. Further details regarding the cooling source are provided in U.S. patent application Ser. No. 11/105,527 (filed on Apr. 14, 2005) and Ser. No. 10/864,410 (filed on Dec. 10, 2005).
In some embodiments, systems of the present invention may comprise one probe; in other embodiments, systems of the present invention may comprise a plurality of, for example two, probes. The system may be operated, for example, in a monopolar mode, a bipolar mode, or a multiphasic/multi-polar mode. When operated in a monopolar mode, any number of probes may be used, and the system may further comprise a dispersive return electrode. The dispersive return electrode may be, for example, a grounding pad for attaching to the patient's skin, or may be a substantially large electrode that is integral with probe 100. When the system is operated in a bipolar mode, any number of probes, for example 2 probes, may be used, and current may travel between the probes. Alternatively, when one probe is used, current may travel between an conductive portion 118 and a second electrically conductive and exposed portion on probe 100. For example, probe 100 may comprise a second electrically conductive and exposed portion in the form of a ring that is disposed around probe 100 at a location proximal to conductive portion 118. Conductive portion 118 and the second electrically conductive and exposed portion may be electrically isolated from each other, and probe 100 may comprise means for operatively connecting the second electrically conductive and exposed portion to a source of energy which is at a different electrical potential than electrode 118, or to a circuit ground.
The operation of the system may be manually controlled by a user, or may be automatically controlled based on certain parameters, for example, based on a measurement of a property of a component of is the system itself or of a property of the tissue being treated. When more than one probe is used, means of controlling the operation of the system may be configured to independently control each probe such that, for example, current flow to any of the probes may be independently adjustable. In addition, a flow of cooling may be controlled independently to each probe. Thus, if one probe is found to be at a higher temperature relative to another probe or probes, flow of cooling to that probe may be increased and/or current flow to that probe may be decreased. Similarly, if one probe is found to be at a lower temperature relative to another probe or probes, flow of cooling to that probe may be decreased and/or current flow to the probe may be increased. In embodiments of a system having automatic control, the system may comprise a controller operable to control one or more devices based on specified criteria. Further details regarding automatic or manual control of the system are provided in U.S. patent application Ser. No. 11/105,527 (filed on Apr. 14, 2005).
In general, embodiments of a method of the present invention involve using a treatment device, for example a probe, in a particular region of a patient's body to form a lesion of sufficient size and suitable geometry to effectively treat the target tissue. For example, in one broad aspect, a method is provided for creating a lesion at a target site within a body of a human or animal using an electrosurgical device having a longitudinal axis. The method may comprise the steps of: inserting the electrosurgical device into the body such that the electrosurgical device is generally upstanding relative to the target site; and delivering energy from an energy source solely through a distal face 107 of the electrosurgical device to the target site for creating the lesion at the target site.
The desired size and geometry of the lesion may depend on the specific anatomy and tissue being targeted and may be affected by several parameters as described herein, including but not limited to the geometry of the treatment device and the amount of cooling delivered to the treatment device. Thus, in accordance with one aspect of the present invention, steps are provided for creating a lesion with desired characteristics during the course of an electrosurgical procedure. The lesion may function to inhibit neural activity, for example nociception. Alternatively, in some embodiments, the lesion may have other effects, for example the shrinkage of collagen. Method embodiments of the present invention generally comprise one or more of the steps of: determining a desired lesion shape, size, and location; selecting an electrosurgical instrument or device, for example a probe, and energy delivery parameters, for example voltage, based on the desired lesion shape, size, and location; inserting the electrosurgical instrument or device into a patient's body; positioning the electrosurgical instrument or device at a target site; delivering energy, for example radiofrequency current, through the electrosurgical instrument or device to the target site to form a lesion; and applying cooling to the electrosurgical instrument or device. As will presently be discussed, embodiments of the method aspect of the present invention may be useful, for example, to allow for more straightforward device placement during electrosurgical procedures than is presently possible.
In one embodiment of the method aspect of the present invention, the step of inserting an electrosurgical instrument or device comprises inserting a probe percutaneously into a patient's body, and the step of positioning an electrosurgical instrument or device comprises advancing the electrosurgical instrument or device until the active electrode is at or in the vicinity of a target treatment site. The step of inserting a probe may optionally be preceded by one or more additional steps including, for example, inserting an introducer apparatus into the body in the vicinity of the target treatment site, measuring one or more properties of a device or of tissue at or near the target treatment site, inserting or removing material at or near the target treatment site, and performing another treatment procedure at or near the target treatment site.
As described above, in some embodiments, the probe may be used in conjunction with an introducer apparatus, which may comprise a cannula and an obturator, for example. In use, the obturator may be initially disposed within a lumen of the cannula to facilitate insertion of the introducer apparatus to the target treatment site. Once the introducer apparatus has been properly positioned, the obturator may be removed and replaced within the cannula lumen by the probe. In some embodiments, as described further herein below, the obturator may be operable to measure the impedance of tissue as the introducer apparatus is inserted into the patient's body which may assist in positioning the introducer apparatus at the target site. Alternatively or in addition, the obturator may be operable to deliver stimulation energy to the target treatment site, as described below. The probe and cannula may be structured such that when the probe is fully disposed within the cannula, the distal end of the probe may be aligned with the distal end of the cannula. In other embodiments, the probe and cannula may be structured such that when the probe is fully disposed within the cannula, the distal end of the probe protrudes or extends from the distal end of the cannula. For example, as described above, if the cannula comprises an electrically conductive elongate member covered by electrically insulating material, with a distal portion that is electrically conductive and exposed, then the probe may be operable to deliver energy from an energy source to the conductive distal portion of the cannula. This delivery of energy may be facilitated by physical contact between the tip of the probe and the inner surface of the cannula. In such an embodiment, the probe tip may be aligned with the distal end of the cannula and the length of the exposed conductive portion of the cannula will affect characteristics of the resulting lesion, as has been described above with reference to
During the steps of inserting and positioning the probe, the probe may be inserted and positioned such that the distal end of the probe, comprising the active electrode, is the portion of the probe that is closest to the treatment site. If the treatment site comprises a surface, for example, the probe may be inserted and positioned substantially perpendicular or generally upstanding to the surface, for example at an angle between about 80° and about 100° relative to the surface. In other embodiments, the probe may be positioned at an angle between about 45° and 135° or, in alternate embodiments, between about 60° and 120°. The probe may be inserted and positioned such that the distal end of the probe is directly adjacent to, or in contact with the target treatment site, or may be inserted and positioned such that the distal end of the probe is proximal to the target site. For example, in one embodiment, a probe may be inserted and positioned using what may be described as a ‘perpendicular’ or ‘gun-barrel’ approach. In this embodiment, the probe may be directed to the target site such that its longitudinal axis is substantially perpendicular or generally upstanding to the line or plane formed by the target tissue or site. For example, if the target tissue is a nerve, the probe may be positioned such that the probe is substantially perpendicular or generally upstanding relative to the nerve. If the target tissue comprises more than one neural structure, such as a nerve or nerve branch, the probe may be inserted and positioned such that it is substantially perpendicular or generally upstanding to a plane containing the neural structures. As will be described in more detail hereinbelow, embodiments of the present invention may allow for the creation of a lesion that is located primarily distally with respect to the distal end of a probe, thus allowing a probe that has been inserted substantially perpendicularly or generally upstanding relative to a target site to effectively treat the target site by delivering energy to form a lesion distal to the probe.
In alternate embodiments, the probe may be inserted at various angles to the target treatment site, depending on the procedure being performed and the anatomical structures involved. For example, in some embodiments, the probe may be inserted such that it is substantially parallel to a target nerve, for example at an angle of between about 0° and about 20°. In other embodiments, the probe may be inserted such that it is at an angle of between about 20° to about 70° to the target site. In general, embodiments of the present invention allow for various angles of approach by providing an apparatus and method of use thereof for creating a lesion of variable size and at various locations relative to the apparatus.
The step of inserting and positioning a probe may involve the insertion of a single probe to a location in the vicinity of a single target treatment site, the insertion of multiple probes in the vicinity of a single target treatment site, or the insertion of multiple probes to multiple locations in the vicinity of multiple target treatment sites. The probe or probes may be configured to deliver energy in a monopolar, bipolar or multi-polar configuration. If the probe or probes are configured to deliver energy in a monopolar configuration, the method of the current invention may also comprise a step of placing a reference electrode, such as a grounding pad, at another location on or in the body. The steps of inserting and positioning a probe may optionally be followed by any number of steps, for example prior to the commencement of the step of delivering energy including, but not limited to, one or more of: measuring one or more properties of a device or of tissue at or near the target treatment site; applying a stimulation signal to a tissue (for example, neural tissue) at or near the target treatment site; measuring the reaction to stimulation (for example, the somato-sensory evoked potential, or SSEP) of a tissue (for example, muscular or neural tissue) in response to the application of a stimulation signal at or near the target treatment site; inserting or removing material at or near the target treatment site; and performing another treatment procedure at or near the target treatment site. Further details regarding these steps may be found in U.S. patent application Ser. No. 11/105,527 (filed on Apr. 14, 2005), Ser. No. 11/280,604 (filed on Nov. 15, 2005), Ser. No. 11/356,706 (filed on Feb. 17, 2006), Ser. No. 11/381,783 (filed on May 5, 2006), and Ser. No. 11/368,509 (filed on Mar. 7, 2006). Following the performance of one or more of the above optional steps, one or more probes may be reinserted, moved, or otherwise repositioned and any optional steps may then be repeated.
In some embodiments, wherein the method comprises the step of measuring the reaction to stimulation, the stimulation energy may be delivered to a location that lies distal to the probe. For example, in embodiments using a cooled probe wherein a lesion is to be formed distal to the distal end of the probe, it may be desired to stimulate the region distal to the distal end of the probe. This can be accomplished by inserting an introducer comprising a stylet that is substantially longer than a cannula. If the stylet extends from the distal end of the cannula to a location where a lesion is expected to form, stimulation energy may be delivered through the stylet, such that the tissue surrounding the distal end of the stylet is stimulated.
The step of delivering energy to the target treatment site, for example to create a lesion at the target treatment site, may involve the creation of a lesion of a desired shape and at a desired location relative to the probe. As mentioned hereinabove, lesion shape and location may be affected by the length of the exposed distal end of the probe. The less of the probe that is exposed, the more distally, relative to the probe, the lesion will form. In addition, the shape of the lesion will be generally more spherical if less of the tip is exposed. For example, if the exposed length of the distal end is limited substantially to the distal-most hemisphere, i.e. the face, of the tip, then a substantially spherical lesion may form primarily distally with respect to the probe. Such a probe may be positioned such that the active electrode of the probe lies substantially proximal from the target site, for example a nerve. Energy may then be delivered to the probe such that a lesion may form substantially distal to the active electrode of the probe. Conversely, if more of the tip is exposed, then the lesion will appear more oblate and may form more radially (i.e. perpendicular to the longitudinal axis of the probe) around the distal end and the component of the lesion distal to the distal end will decrease.
The type, parameters, and properties of the energy delivered to the probe may vary depending on the application, and the invention is not limited in this regard. The energy may be one of various types of energy, for example electromagnetic, microwave, or thermal. In some embodiments, radiofrequency electrical current having a frequency of between about 10 kHz and about 1000 kHz, at a power of about 50 W, may be delivered to the probe.
In some embodiments of the method of the present invention, the step of delivering energy to the tissue may be preceded by, and/or done coincidently with, a step of applying cooling. Cooling may be used to reduce the temperature of the tissue in the vicinity of the site of energy delivery, allowing more energy to be applied without causing an increase to an unsafe temperature in local tissue. The application of more energy allows regions of tissue further away from the electrode(s) to reach a temperature at which a lesion can form, thus increasing the maximum size/volume of the lesion. Furthermore, depending on the structure of the probe, cooling may allow for a lesion to form at a position that is substantially distal to and, in some embodiments, spaced from the probe. Further details regarding cooled probes are disclosed in U.S. Provisional Patent Application 60/743,511 (Filed on Mar. 16, 2006), and 60/595,559 (Filed on Jul. 14, 2005), both of which are incorporated herein by reference. Thus, cooling an electrosurgical probe may change the size, shape, and location of formation of a lesion. As noted above, the theory described herein regarding tissue heating and lesion formation is not intended to limit the present invention in any way.
In one embodiment, a step of applying cooling may be used to facilitate the creation of a lesion that is distal to probe 100 and which is spaced from probe 100, as shown in
Additionally, cooling may be modulated during energy delivery (and in some cases, accompanied by modulation of energy delivery) as follows: energy may be delivered initially in conjunction with cooling so that a lesion begins to form at some distance distally spaced apart from the probe; cooling may then be reduced, causing the lesion to extend at least partially in the direction of the probe. Thus, a further aspect of some embodiments of the method aspect of the present invention involves the control of cooling parameters in order to create a lesion at a desired location relative to the probe. For example, an 18 AWG probe having an exposed distal tip about 1.5 mm to about 2 mm in length and being cooled by a cooling fluid having a temperature of less than 30 degrees Celsius at a rate of at least 10 mL/minute, will form a lesion about 1.5 mm distal to the probe tip. As the cooling is decreased, for example by lowering the fluid flow rate, the lesion will form closer to the probe tip. As has been mentioned with respect to adjusting the exposed length of the distal end, cooling parameters may be adjusted before, during or after energy delivery.
Thus, embodiments of a method aspect of the present invention provide for creating a lesion having a desired shape, size and location based on one or more factors, including, but not limited to, probe geometry and degree of cooling. The desired lesion parameters may be determined by a user in advance of a treatment procedure based, in some embodiments, on the specific tissue being targeted, as well as individual patient anatomy. For example, in procedures wherein the target site for formation of a lesion is located within a fissure, groove, or rut in a bone, it may not be possible to position the probe at the target site, and thus it may be desired to position the probe 100 at a location spaced from the target site. In this case, the user may select a probe 100 wherein the electrically exposed conductive portion 118 comprises only the distal face 107 of the probe, and may select a high flow and/or low temperature of cooling fluid. Such a configuration may allow for the formation of a lesion distal to the probe tip 118, thus allowing the probe tip 118 to be located at some distance from the target site. If the probe 100 is positioned substantially perpendicular to the target site, a lesion may form at a location distal to the distal end of the probe, i.e. within the fissure in the bone. In another example, the target site may be directly on the surface of a bone. In this case the user may select a probe 100 wherein the conductive portion 118 extends along the shaft proximally from the distal end, and may select a moderate or low amount of cooling. The user may position the distal end of the probe adjacent to the target site, for example about 0.1 to about 3 mm from the target site, or may allow the distal end of the probe 100 to touch the bone, and may orient the probe such that the longitudinal axis of the probe 100 is substantially perpendicular to the bone. In this case a lesion may form around the conductive portion of the probe 100, and between the distal end of the probe 100 and the bone. Alternatively, the aforementioned probe 100 having an electrode 118 comprising only the exposed distal face 107 may be used in this case as well. In both of these examples, a probe 100 with an adjustable insulating sheath may be used to provide an appropriately sized exposed electrode 118 to produce the desired lesion. Alternatively, as mentioned hereinabove, the position of a probe within a cannula or introducer may be altered by advancing and/or retracting the probe to provide an appropriately sized exposed electrode 118 to produce the desired lesion.
In some embodiments, two cooled probes 100 in a bipolar configuration may be used, which may allow for the creation of a substantially uniform lesion between the electrodes of the two probes 100. This concept is illustrated in
In some embodiments, after the creation of a lesion, the probe 100 may be repositioned, and energy may again be delivered in order to form a further lesion. For example, after the formation of a first lesion, the probe 100 may be withdrawn from the target site either partially or fully. In the case of partial withdrawal, energy may be delivered to the site at which the probe 100 has been withdrawn to, such that a further lesion is formed. In the case of full withdrawal, the probe may be re-inserted and re-positioned at a second location, and energy may be delivered to the second location to form a further lesion. The step of repositioning may be performed any number of times, to form any number of lesions, as determined by a user. In embodiments comprising a steerable probe, the probe may be repositioned without withdrawing the probe, by actuating the steering means associated with the probe.
Methods of the present invention may be used for various applications, including for the treatment of pain associated with many conditions. Examples of such conditions include, but are not limited to, Complex Regional Pain Syndrome (CRPS), Trigeminal Neuralgia, Joint Specific Peripheral Neuropathy, Facet Joint Pain, Intervertebral disc pain, Sacroiliac Joint Syndrome (SIJS) and Hypogastric or Pelvic Pain. In general, these conditions may be treated by affecting at least one target neural structure that may be associated with a patient's pain in accordance with method embodiments of the present invention. For example, in the case of trigeminal neuralgia, embodiments of the present invention may be used to form a lesion at the trigeminal nerve. Some embodiments of a method of the present invention may also be used to treat further sources of pain, as will be described in more detail hereinbelow.
In some embodiments of the present invention, the use of an introducer apparatus may not be required to insert a probe into a patient's body. For example, as is disclosed in co-pending U.S. patent application Ser. No. 11/207,707 (Filed on Aug. 22, 2005), incorporated herein by reference, an electrosurgical device or instrument, for example a probe, may be structured such that it is capable of piercing skin as well as delivering energy. The electrosurgical instrument or device may further be capable of delivering fluids to a target site. Therefore, in such embodiments, the electrosurgical device or instrument may be percutaneously inserted into the patient and directed to the target site without the use of a separate introducer apparatus.
In some embodiments, any or all of the method steps described above may be performed with the aid of imaging. For example, the step of inserting a probe may be performed under X-ray fluoroscopic guidance. In a further embodiment, the imaging may be performed in a gun-barrel manner, wherein the device is visualized along its longitudinal axis.
In some embodiments, rather than being delivered in a continuous manner, energy may be delivered in a series of amplitude or frequency modulated pulses, whereby tissue heating is inhibited by interrupting periods of energy delivery with periods in which energy is delivered at a lower voltage. In one specific embodiment, energy is delivered according to a set duty cycle of signal on time/off time, wherein the signal is ‘on’ less than 100% of the time, as follows: during signal ‘on time’ energy is delivered at a voltage that may beneficially be higher than voltages that can safely be used during continuous energy delivery (100% duty cycle) procedures; during signal ‘off time’, the heat generated in the vicinity of the probe may disperse throughout the tissue, raising the temperature of tissue away from the probe, while tissue in the vicinity of the probe drops; energy is again applied and the delivery is cycled through ‘on time’ and ‘off time’ until a predetermined endpoint (e.g. time or temperature) is reached or until a practitioner decides to end the treatment. The reduction in temperature of tissue in the vicinity of the probe during signal ‘off time’ may allow a higher voltage to be used (during ‘on time’), than would tend to be used in a continuous energy delivery procedure. In this way, the pulsing of energy delivery, either between signal ‘on time’ and ‘off time’, as described above, or between a higher voltage and a lower voltage (for example, a voltage capable of generating a lesion in the tissue and a voltage not capable of generating a lesion in the tissue, given the frequency of energy being delivered), the total amount of current deposited into the tissue may be sufficient to create a larger lesion, at a further distance from the probe, than would be possible using continuous energy delivery without maintaining the tissue in the vicinity of the probe at a temperature that may cause charring.
In further embodiments, the step of cooling the probe may be performed in a pulsed or intermittent manner. This may allow for a more accurate measurement of tissue temperature by a temperature sensing device associated with the probe. For example, in embodiments wherein the probe is cooled via the internal circulation of a cooling fluid delivered by a pump, the pump may be operated in a pulsed or intermittent manner. When the pump is ‘on’, fluid will circulate within the probe, and the probe and surrounding tissue will be cooled; when the pump is ‘off’, fluid will not circulate within the probe, and heat from the tissue in the vicinity of the probe 100 may conduct back towards the probe, causing the probe to heat to a temperature that is more indicative of the temperature of the tissue in the vicinity of the probe 100. The temperature sensing device may sense this temperature, and may thus give a more accurate reading of the temperature of the tissue in the vicinity of the probe 100. When the pump returns to the ‘on’ position, the probe 100 will again be cooled, and the tissue adjacent the probe will return to a cooler temperature. The pulsing of the pump may coincide with pulsing of energy delivered to the probe 100, such that cooling is only supplied to the probe 100 while energy is being delivered.
In some embodiments, the amount or degree of cooling supplied to the probe 100 may be controlled actively by a user by modifying a flow-rate, or a temperature of the cooling fluid. For example, a temperature measured at the distal region of a probe may be displayed on a screen or other display means. Based on this temperature, a user may desire to increase the amount of cooling supplied to the probe 100, for example if the temperature is above a certain threshold level. The user may, in some embodiments, adjust the amount of cooling supplied by increasing the flow-rate of cooling fluid. This may be accomplished by turning a knob on a pump, for example, or by opening a valve. In other embodiments, the control of cooling may be passive and/or automatic. For example, a computer may automatically adjust a fluid flow-rate based on a temperature measured at the distal region of the probe 100. In another example, a fluid flow-rate may be fixed during the course of a treatment procedure, and may not be modified.
As has been mentioned, a system of the present invention may be used to produce a generally uniform or substantially homogeneous lesion substantially between two probes when operated in a bipolar mode. In certain cases, generally uniform or substantially homogeneous lesions may be contraindicated, such as in a case where a tissue to be treated is located closer to one active electrode than to the other. In cases where a uniform lesion may be undesirable, using two or more cooled probes in combination with a suitable feedback and control system may allow for the creation of lesions of varying size and shape. For example, preset temperature and/or power profiles that the procedure should follow may be programmed into a generator prior to commencement of a treatment procedure. These profiles may define parameters (these parameters would depend on certain tissue parameters, such as heat capacity, etc.) that should be used in order to create a lesion of a specific size and shape. These parameters may include, but are not limited to, maximum allowable temperature, ramp rate (i.e. how quickly the temperature is raised) and the rate of cooling fluid flow, for each individual probe. Based on temperature or impedance measurements performed during the procedure, various parameters, such as power or cooling, may be modulated, in order to comply with the preset profiles, resulting in a lesion with the desired dimensions. Similarly, it is to be understood that a uniform lesion can be created, using a system of the present invention, using many different pre-set temperature and/or power profiles which allow the thermal dose across the tissue to be as uniform as possible, and that the present invention is not limited in this regard.
Embodiments of the method aspect of the present invention may be useful for creating a lesion having a desired shape, size and/or location within various tissues of a human or animal. More specifically, some embodiments of the present invention may comprise treatment procedures for treating one or more target tissue sites associated with a patient's vertebral column. For example, treatment procedures may be performed at various locations external to the vertebrae, including but not limited to target sites at the cervical, thoracic, lumbar and sacral regions of the spine. In addition, treatment procedures may be performed at target sites within the vertebrae themselves, referred to as an intraosseous procedure. Furthermore, treatment procedures may be performed at target sites within one or more intervertebral discs. Although several exemplary embodiments of such procedures will be presently described, the present invention is not limited to such procedures and may be practiced at various target sites within a patient's body. In any or all of the embodiments disclosed herein, a treatment procedure may comprise a step of determining desired lesion parameters, including, but not limited to, shape, size and location, and selecting probe geometry, location and cooling in order to create the desired lesion.
One application of an embodiment of a method of the present invention is for the treatment of pain within or in the vicinity of an intervertebral disc. As is disclosed in U.S. Pat. No. 6,896,675 (filed on Mar. 5, 2002), and U.S. Pat. No. 6,562,033 (filed on Apr. 9, 2001), and U.S. patent application Ser. No. 11/128,342 (filed on May 13, 2005), Ser. No. 11/105,527 (filed on Apr. 14, 2005), Ser. No. 11/105,490 (filed on Apr. 14, 2005), and Ser. No. 11/105,524 (filed on Apr. 14, 2005), all of which are incorporated herein by reference, RF energy may be delivered through a cooled probe to an intervertebral disc of a patient in order, for example, to treat pain. Treatment of an intervertebral disc may generally comprise the steps of: inserting at least one probe into the intervertebral disc of a patient; and delivering energy through the probe(s) to the tissue of the intervertebral disc. As described above, the at least one probe may be cooled and the degree of cooling may affect the size, shape and/or location of a lesion formed within the disc.
Referring to
A method embodiment of the present invention may also be used to treat intraosseous target sites, i.e. target sites within a bony structure. Such procedures can be used to, for example, treat a tumor in the bony structure or lesion a neural structure within the bone. In an intraosseous procedure, one or more introducers may generally be used to gain access to the bone to be treated, for example, a vertebra of a spinal column. In such embodiments, the introducers may comprise a drill or other means for accessing the bone. Alternatively or in addition, a hammer or a reamer may be used to access an intraosseous site. As is the case with procedures related to intervertebral discs, one or more probes may be inserted at a site or sites within a bone and energy may be delivered to active electrodes located at the distal regions of the probes. Energy may be delivered in a bipolar mode, or in a monopolar mode. Furthermore, as mentioned above, one or more of the probes may be cooled to allow for the formation of a lesion having a desired size, shape and location.
Another application of embodiments of the apparatus and method of the present invention is for the treatment of pain emanating from a patient's neck, i.e. the cervical region of the spine, as is disclosed in U.S. Provisional Patent Application 60/743,511 (filed on Mar. 16, 2006), incorporated herein by reference.
Referring now to
A method of treating cervical/neck pain in accordance with one embodiment of the present invention will be presently described. The description will reference the anatomy of the facet nerve of the fourth cervical vertebra; however persons of skill in the art will recognize that the method may be used to treat other nerves of other cervical vertebrae as well, for example the third occipital nerve of the third cervical vertebra. Variations of the described method may be required in order to accommodate anatomical differences of other cervical vertebrae. In some embodiments, the target site for treating cervical/neck pain may comprise the nerves innervating the facet joint. As described hereinabove, these nerves may be located substantially adjacent to the articular pillar of the cervical vertebra. Thus the target site for energy delivery may be the region located slightly cephalad to the centroid of the articular pillar, as shown in
In one specific embodiment, the patient may be placed in the prone position in preparation for the treatment procedure. The user may optionally administer various treatments, such as anesthetics or antibiotics, for example. The user may insert at least one probe, such as probe 100 described hereinabove, percutaneously towards the target site. The step of inserting at least one probe may comprise the use of an introducer apparatus, as described herein above. Such an apparatus may be an introducer apparatus comprising cannula 604 and obturator 606. The user may insert the introducer apparatus percutaneously into the patient via a lateral approach, such that the longitudinal axis of the cannula is substantially perpendicular or generally upstanding, for example at an angle of about 80° to about 100°, relative to the target site, i.e. the centroid of the articular pillar. In other words, the longitudinal axis of the cannula may be substantially perpendicular or generally upstanding to the anterior-posterior (AP) axis of the body, as shown in
When the introducer apparatus has been positioned, the user may withdraw the obturator/stylet from the cannula, leaving the cannula in place. Depending on the positioning of the introducer apparatus, the distal end of the cannula may now be touching the bone, or may be some distance proximal from the bony surface, for example about 3 mm away from the bone. The user may then insert a probe into the lumen of the cannula. The probe may be operatively connected to a source of cooling fluid, for example pumps 610, and may further be operatively connected to a source of energy, such as generator 608, in order to deliver energy to the target site.
As described above, depending on the configuration and positioning of the probe, as well as the degree of cooling, the lesion formed at the target site may be of a variety of shapes and sizes, as described hereinabove. For example, as shown in
Another application of embodiments of a method of the present invention is for the treatment of pain in the lumbar region of a patient's spine. With reference now to
A method of treating lumbar pain in accordance with an embodiment of the present invention will be presently described. The description will reference the anatomy of the first lumbar vetrebra; however persons of skill in the art will recognize that the method may be used to treat other lumber vertebrae as well. Variations of the described method may be required in order to accommodate anatomical differences of other lumbar vertebrae. In some embodiments, the target site for treating lumbar pain may comprise the nerves innervating the facet joint. As described hereinabove, these nerves may be located substantially adjacent to the articular process of the lumbar vertebra. Thus the target site for energy delivery may be the dorsal surface of the transverse process just caudal to the most medial end of the superior edge of the transverse process.
In one specific embodiment, the patient may be placed in the prone position in preparation for the treatment procedure. The user may optionally administer various treatments, such as anesthetics or antibiotics, for example. The user may insert at least one probe, such as probe 100 described hereinabove, percutaneously toward the target site. In general, due to the large and controllable lesion size afforded by the structure of probe 100, probe 100 may be inserted from a number of angles and positioned at a wide variety of locations to create a lesion at the target site. The step of inserting at least one probe may comprise the use of an introducer apparatus. Such an apparatus may be an introducer apparatus comprising cannula 604 and obturator 606. The user may insert the introducer apparatus percutaneously into the patient via several different approaches. For example, in one embodiment, the introducer may be inserted in the saggital plane of the medial branch one or two levels caudal to the target site, and may be advanced in a rostral and anterior direction. In another embodiment, the introducer may be advanced from a more lateral position with oblique medial angulation. In other embodiments, the probe may be introduced at other sites, and inserted at other angles. The insertion step may be facilitated with the use of fluoroscopic imaging techniques. The user may continue the insertion until a distal end of the introducer apparatus contacts the dorsal surface of the transverse process just caudal to the most medial end of the superior edge of the transverse process, or may stop the insertion when the distal end lies some distance, for example about 2 to about 4 millimeters, proximal from the surface. In other embodiments, the user may contact the surface of the transverse process with the tip of the introducer, and may then retract the introducer apparatus such that the distal end lies some distance proximal from the surface. In some embodiments, the user may use depth stoppers to aid in the marking and/or maintaining the position of the introducer apparatus within the patient's body.
Depending on the configuration and positioning of the probe, as well the degree of cooling supplied to the probe, the lesion formed at the target site may be of a variety of shapes and sizes, as described hereinabove. For example, as shown in
Referring now to
Due to the varied course of the medial branch across the 12 thoracic levels, the lack of bony landmarks associated with the thoracic medial branch, and the anatomic differences among patients, it is often required to create several lesions in order to denervate one thoracic facet joint, as is described by Dreyfuss et al (ISIS Newsletter, December 1997, Volume 2, Number 6). Embodiments of the present invention may allow for the formation of a single large lesion for the denervation of a facet joint, for example by using cooling, thus providing a more straightforward and less invasive procedure.
A method of treating thoracic pain in accordance with an embodiment of the present invention will be presently described. The description will reference the anatomy of the first through tenth thoracic vertebrae. Variations of the described method may be required in order to accommodate anatomical differences of other thoracic vertebrae. In some embodiments, the target site for treating thoracic pain may comprise the nerves innervating the facet joint. As described hereinabove, these nerves may be located substantially laterally between two consecutive transverse processes, or substantially adjacent the superior edge of a transverse process. Thus the target site 1310 for energy delivery may be the superior lateral edge of the transverse process and the region immediately superior thereto.
In one specific embodiment, the patient may be placed in the prone position in preparation for the treatment procedure. The user may optionally administer various treatments, such as anesthetics or antibiotics, for example. The user may insert at least one probe, such as probe 100 described hereinabove, percutaneously toward the target site. In general, due to the large and controllable lesion size afforded by the structure of probe 100, probe 100 may be inserted from a number of angles and positioned at a wide variety of locations to create a lesion at the target site. The step of inserting at least one probe may comprise the use of an introducer apparatus. Such an apparatus may be an introducer apparatus comprising cannula 604 and obturator 606.
The user may insert the introducer apparatus percutaneously into the patient via several different approaches. For example, as shown in
Depending, for example, on the configuration and positioning of the probe, as well as the degree of cooling supplied to the probe, the lesion formed at the target site may be of a variety of shapes and sizes, as described hereinabove. For example, as shown in
A further application of embodiments of the apparatus and method of the present invention is for the treatment of pain emanating from the Sacroiliac (SI) joint and/or the surrounding region. Some details regarding such a treatment procedure are disclosed in U.S. patent application Ser. No. 11/280,604 (filed on Nov. 15, 2005) and Ser. No. 11/356,706 (filed on Feb. 17, 2006), and U.S. Provisional Patent Application 60/627,813 (filed on Nov. 15, 2004), 60/593,839 (filed on Feb. 17, 2005), 60/594,787 (filed on May 5, 2005), 60/595,426 (filed on Jul. 4, 2005), 60/595,559 (filed on Jul. 14, 2005), 60/595,560 (filed on Jul. 14, 2005), and 60/743,663 (filed on Mar. 22, 2006), all of which are incorporated herein by reference. The SI joint 1500 is the joint between the sacrum 1502, a large bone at the base of the spine composed of five fused vertebrae, and the ilium 1504 of the pelvis. The SI joint is a relatively immobile joint, serving to absorb shock during locomotion. The structure of the SI joint and surrounding tissues varies significantly between individuals but generally comprises an articular cartilaginous surface, a ligamentous aspect and, in most cases, one or more synovial recesses. Though the specific pathways of SI joint innervation have not yet been elucidated, the nerves responsible for SI pain are thought to comprise, at least in part, nerves emanating from the dorsal sacral plexus, the network of nerves on the posterior surface of the sacrum, extending from the sacral nerves, also referred to as the posterior primary rami 1506, that exit the sacral foramina 1508 (posterior sacral foramen). The lateral branches 1510 branch out from the sacral nerves (and branch out further along the sacrum as well) and are thought to play a role in the innervation of the SI joint. The surface of the sacrum can be very uneven, inhibiting the ability of a small lesion to affect nerves running along crests of the sacrum, as well as those within the grooves or recesses in the sacral surface; furthermore, accessing the sacrum can require penetrating the sacroiliac ligaments, ligaments responsible for bearing a large proportion of the weight of the body and which, desirably, would be severed or weakened as little as possible.
Due to the anatomy of the sacrum, a straight ‘gun-barrel’ approach, substantially perpendicular to the plane of the sacrum or to the target site, may be desirable. However, if a target nerve to be lesioned is running through a narrow groove or fissure that is too narrow to accommodate a probe capable of creating a lesion with the desired volume, the nerve may remain distal to an inserted probe, even if the probe is in contact with the surface of the sacrum. Embodiments of the device of the present invention may be used according to embodiments of the method described above in order to create a lesion that is primarily located distal to probe 100. This may allow for a substantially perpendicular ‘gun-barrel’ approach and a lesion thus created may encompass the target nerve.
In some embodiments, it may be desired to treat one or more neural structures within a sacral neural crescent. The term ‘sacral neural crescent’ refers to an area lateral to each of the sacral foramina, through which the sacral nerves are believed to pass after exiting the foramina. On the dorsal right side of the sacrum, this window is from about 12 o'clock to about 6 o'clock in a clockwise direction, while on the dorsal left side of the sacrum the window is from about 6 o'clock to about 12 o'clock in a clockwise direction. Similar (but in the counter-clockwise direction) areas exist on the ventral side of the sacrum. The clock positions are referenced as if the foramen is viewed as a clock face, and the view is taken looking towards the sacrum. For reference, the 12 o'clock position of the clock face would be the most cephalad (towards the head) point of the foramen.
In other embodiments, methods of the present invention may be used to treat other conditions at various regions within the body, which may be external to the patient's spine. Examples of such conditions include, but are not limited to, pain-causing conditions such as Complex Regional Pain Syndrome (CRPS), Trigeminal Neuralgia, Joint Specific Peripheral Neuropathy, Facet Joint Pain, Fibrotic pain or pain due to scar tissue, and Hypogastric or Pelvic Pain. In general, these conditions may be treated by lesioning at least one target nerve that may be associated with a patient's pain in accordance with method embodiments of the present invention. For example, in the case of trigeminal neuralgia, devices and methods of the present invention may be used to form a lesion at the trigeminal nerve. In the case of CPRS, devices and methods of the present invention may be used to form a lesion at a sympathetic nerve chain.
In addition to the treatment of pain-causing conditions, methods and devices of the present invention may be used for other applications, such as cardiac ablation, for example in cases of atrial tachycardia, is removal or treatment of scar tissue, treatment of varicose veins, treatment of hyperparathyroidism, and ablation of malignancies or tumours, for example in the lung, liver, or bone. In general, these conditions may be treated by lesioning at least one target site associated with a symptom or cause of a patient's condition. For example, in the case of atrial tachycardia, devices and methods of the present invention may be used to form a lesion at the His Bundle region of the heart. In the case of hyperparathyroidism, devices and methods of the present invention may be used to form a lesion at one or more parathyroid glands.
The embodiments of the invention described above are intended to be exemplary only. The scope of the invention is therefore intended to be limited solely by the scope of the appended claims.
It is appreciated that certain features of the invention, which are, for clarity, described in the context of separate embodiments, may also be provided in combination in a single embodiment. Conversely, various features of the invention, which are, for brevity, described in the context of a single embodiment, may also be provided separately or in any suitable subcombination.
Although the invention has been described in conjunction with specific embodiments thereof, it is evident that many alternatives, modifications and variations will be apparent to those skilled in the art. Accordingly, it is intended to embrace all such alternatives, modifications and variations that fall within the spirit and broad scope of the appended claims. All publications, patents and patent applications mentioned in this specification are herein incorporated in their entirety by reference into the specification, to the same extent as if each individual publication, patent or patent application was specifically and individually indicated to be incorporated herein by reference. In addition, citation or identification of any reference in this application shall not be construed as an admission that such reference is available as prior art to the present invention.
This application is a continuation-in-part of U.S. patent application Ser. No. 11/105,527 (filed on Apr. 14, 2005), Ser. No. 11/105,490 (filed on Apr. 14, 2005), and Ser. No. 11/105,524 (filed on Apr. 14, 2005), all of which claim the benefit of U.S. Provisional Patent Application 60/604,348 (filed on Aug. 25, 2004), and are continuations-in-part of U.S. patent application Ser. No. 10/087,856 (filed on Mar. 5, 2002), now U.S. Pat. No. 6,896,675. This application is also a continuation-in-part of U.S. patent application Ser. No. 11/381,783 (filed on May 5, 2006). This application is also a continuation-in-part of U.S. patent application Ser. No. 10/864,410 (filed on Jun. 10, 2004). This application is also a continuation-in-part of U.S. patent application Ser. No. 11/207,707 (filed on Aug. 22, 2005). U.S. patent application Ser. No. 11/207,707 is a continuation-in-part of U.S. patent application Ser. No. 11/079,318 (filed on Mar. 15, 2005) which is a continuation-in-part of U.S. patent application Ser. No. 10/382,836 (filed on Mar. 7, 2003). U.S. patent application Ser. No. 11/207,707 is also a continuation-in-part of U.S. patent application Ser. No. 11/125,247 (filed on May 10, 2005), which is a continuation-in-part of Ser. No. 10/853,126 (filed on May 26, 2004). This application also claims the benefit of U.S. Provisional Patent Application 60/743,511 (filed on Mar. 16, 2006), 60/595,559 (filed on Jul. 14, 2005), 60/595,560 (filed on Jul. 14, 2005), and 60/744,518 (filed on Apr. 10, 2006). All of the aforementioned patents and applications are incorporated herein by reference, in their entirety.
| Number | Name | Date | Kind |
|---|---|---|---|
| 4041931 | Elliott et al. | Aug 1977 | A |
| 4202349 | Jones | May 1980 | A |
| 4257429 | Dickhudt et al. | Mar 1981 | A |
| 4419095 | Nebergall et al. | Dec 1983 | A |
| 4447239 | Krutten | May 1984 | A |
| 4548027 | Reimels | Oct 1985 | A |
| 4612934 | Borkan | Sep 1986 | A |
| 4657024 | Coneys | Apr 1987 | A |
| 5191900 | Mishra | Mar 1993 | A |
| 5209749 | Buelna | May 1993 | A |
| 5342343 | Kitaoka et al. | Aug 1994 | A |
| 5342357 | Nardella | Aug 1994 | A |
| 5397338 | Grey et al. | Mar 1995 | A |
| 5423807 | Milder | Jun 1995 | A |
| 5429597 | DeMello et al. | Jul 1995 | A |
| 5429617 | Hammersmark et al. | Jul 1995 | A |
| 5433739 | Sluijter et al. | Jul 1995 | A |
| 5545193 | Fleischman et al. | Aug 1996 | A |
| 5571147 | Sluijter et al. | Nov 1996 | A |
| 5688267 | Panescu et al. | Nov 1997 | A |
| 5693043 | Kittrell et al. | Dec 1997 | A |
| 5759174 | Fischell et al. | Jun 1998 | A |
| 5766171 | Silvestrini | Jun 1998 | A |
| 5776092 | Farin et al. | Jul 1998 | A |
| 5779642 | Nightengale | Jul 1998 | A |
| 5800428 | Nelson et al. | Sep 1998 | A |
| 5855577 | Murphy-Chutorian et al. | Jan 1999 | A |
| 5895386 | Odell | Apr 1999 | A |
| 5951546 | Lorentzen | Sep 1999 | A |
| 6002964 | Feler et al. | Dec 1999 | A |
| 6056743 | Ellis et al. | May 2000 | A |
| 6102886 | Lundquist et al. | Aug 2000 | A |
| 6104957 | Alo et al. | Aug 2000 | A |
| 6112123 | Kelleher et al. | Aug 2000 | A |
| 6126654 | Giba et al. | Oct 2000 | A |
| 6129726 | Edwards | Oct 2000 | A |
| 6146380 | Racz et al. | Nov 2000 | A |
| 6176857 | Ashley | Jan 2001 | B1 |
| 6235000 | Milo et al. | May 2001 | B1 |
| 6251104 | Kesten et al. | Jun 2001 | B1 |
| 6277112 | Underwood et al. | Aug 2001 | B1 |
| 6280441 | Ryan | Aug 2001 | B1 |
| 6306132 | Moorman et al. | Oct 2001 | B1 |
| 6315790 | Gerberding et al. | Nov 2001 | B1 |
| 6355033 | Moorman et al. | Mar 2002 | B1 |
| 6379349 | Müller et al. | Apr 2002 | B1 |
| 6464723 | Callol | Oct 2002 | B1 |
| 6471700 | Burbank et al. | Oct 2002 | B1 |
| 6478793 | Moorehead | Nov 2002 | B1 |
| 6501992 | Belden et al. | Dec 2002 | B1 |
| 6562033 | Shah et al. | May 2003 | B2 |
| 6575969 | Rittman et al. | Jun 2003 | B1 |
| 6582426 | Moorman et al. | Jun 2003 | B2 |
| 6620156 | Garito | Sep 2003 | B1 |
| 6622731 | Daniel et al. | Sep 2003 | B2 |
| 6726684 | Woloszko | Apr 2004 | B1 |
| 6735474 | Loeb et al. | May 2004 | B1 |
| 6757565 | Sharkey | Jun 2004 | B2 |
| 6770070 | Balbierz | Aug 2004 | B1 |
| 6773446 | Dwyer et al. | Aug 2004 | B1 |
| 6780181 | Kroll et al. | Aug 2004 | B2 |
| 6847849 | Mamo et al. | Jan 2005 | B2 |
| 6893421 | Larsen et al. | May 2005 | B1 |
| 6902526 | Katzman | Jun 2005 | B2 |
| 6932811 | Hooven | Aug 2005 | B2 |
| 6966902 | Tsugita et al. | Nov 2005 | B2 |
| 6974454 | Hooven | Dec 2005 | B2 |
| 7097641 | Arless et al. | Aug 2006 | B1 |
| 7175631 | Wilson et al. | Feb 2007 | B2 |
| 7306596 | Hillier | Dec 2007 | B2 |
| 7462178 | Woloszko et al. | Dec 2008 | B2 |
| 8475448 | Sharareh et al. | Jul 2013 | B2 |
| 9173700 | Godara | Nov 2015 | B2 |
| 9364281 | Lefler | Jun 2016 | B2 |
| 9820808 | Lefler | Nov 2017 | B2 |
| 20010000041 | Selmon et al. | Mar 2001 | A1 |
| 20010027309 | Elsberry | Oct 2001 | A1 |
| 20010056280 | Underwood | Dec 2001 | A1 |
| 20020026127 | Balbierz | Feb 2002 | A1 |
| 20020032440 | Hooven | Mar 2002 | A1 |
| 20020049437 | Silvestrini | Apr 2002 | A1 |
| 20020072739 | Lee | Jun 2002 | A1 |
| 20020091384 | Godinho de Queiroz e Melo | Jul 2002 | A1 |
| 20020103484 | Hooven | Aug 2002 | A1 |
| 20020120260 | Morris et al. | Aug 2002 | A1 |
| 20020147485 | Mamo et al. | Oct 2002 | A1 |
| 20020193781 | Loeb | Dec 2002 | A1 |
| 20030014047 | Woloszko | Jan 2003 | A1 |
| 20030015707 | Bosco | Jan 2003 | A1 |
| 20030023239 | Burbank et al. | Jan 2003 | A1 |
| 20030032936 | Lederman | Feb 2003 | A1 |
| 20030040742 | Underwood | Feb 2003 | A1 |
| 20030093007 | Wood | May 2003 | A1 |
| 20030100895 | Simpson et al. | May 2003 | A1 |
| 20030109870 | Lee | Jun 2003 | A1 |
| 20030125729 | Hooven | Jul 2003 | A1 |
| 20030153906 | Sharkey | Aug 2003 | A1 |
| 20030158545 | Hovda et al. | Aug 2003 | A1 |
| 20030171744 | Leung | Sep 2003 | A1 |
| 20030212394 | Pearson et al. | Nov 2003 | A1 |
| 20030212395 | Woloszko | Nov 2003 | A1 |
| 20030233125 | Kaplan et al. | Dec 2003 | A1 |
| 20040054366 | Davidson et al. | Mar 2004 | A1 |
| 20040082942 | Katzman | Apr 2004 | A1 |
| 20040106891 | Langan et al. | Jun 2004 | A1 |
| 20040187875 | He et al. | Sep 2004 | A1 |
| 20040199161 | Truckai et al. | Oct 2004 | A1 |
| 20040215287 | Swoyer et al. | Oct 2004 | A1 |
| 20040249373 | Gronemeyer et al. | Dec 2004 | A1 |
| 20040267203 | Potter et al. | Dec 2004 | A1 |
| 20040267254 | Manzo et al. | Dec 2004 | A1 |
| 20050033372 | Gerber et al. | Feb 2005 | A1 |
| 20050049570 | Chin et al. | Mar 2005 | A1 |
| 20050085806 | Auge II et al. | Apr 2005 | A1 |
| 20050096718 | Gerber et al. | May 2005 | A1 |
| 20050177209 | Leung et al. | Aug 2005 | A1 |
| 20050177211 | Leung et al. | Aug 2005 | A1 |
| 20050187542 | Auge | Aug 2005 | A1 |
| 20050240238 | Mamo | Oct 2005 | A1 |
| 20060020297 | Gerber et al. | Jan 2006 | A1 |
| 20060025763 | Nelson et al. | Feb 2006 | A1 |
| Number | Date | Country |
|---|---|---|
| 1160932 | Jan 1984 | CA |
| 0547772 | Jun 1993 | EP |
| 0642800 | Mar 1995 | EP |
| 0651661 | Jun 2000 | EP |
| 0865768 | Feb 2003 | EP |
| 1344497 | Sep 2003 | EP |
| WO 8103272 | Nov 1981 | WO |
| WO 94002077 | Feb 1994 | WO |
| WO 94009560 | Apr 1994 | WO |
| WO 94022384 | Oct 1994 | WO |
| WO 94024948 | Nov 1994 | WO |
| WO 95010318 | Apr 1995 | WO |
| WO 95010320 | Apr 1995 | WO |
| WO 95010327 | Apr 1995 | WO |
| WO 95021578 | Aug 1995 | WO |
| WO 96039967 | Dec 1996 | WO |
| WO 97006739 | Feb 1997 | WO |
| WO 97006855 | Feb 1997 | WO |
| WO 97024074 | Jul 1997 | WO |
| WO 9819613 | May 1998 | WO |
| WO 98027879 | Jul 1998 | WO |
| WO 98031290 | Jul 1998 | WO |
| WO 98058747 | Dec 1998 | WO |
| WO 99042037 | Aug 1999 | WO |
| WO 1999043263 | Sep 1999 | WO |
| WO 1999048548 | Sep 1999 | WO |
| WO 2001045579 | Jun 2001 | WO |
| WO 2001067975 | Sep 2001 | WO |
| WO 2001070114 | Sep 2001 | WO |
| WO 2001074251 | Oct 2001 | WO |
| WO 2001080724 | Nov 2001 | WO |
| WO 2002045609 | Jun 2002 | WO |
| WO 2003037162 | May 2003 | WO |
| WO 2003065917 | Aug 2003 | WO |
| WO 2003103522 | Dec 2003 | WO |
| Entry |
|---|
| Valleylab—RF Pain Management System, Sep. 16, 2004, http://www.valleylab.com/static/pain/products-generator.html. |
| Number | Date | Country | |
|---|---|---|---|
| 20070027449 A1 | Feb 2007 | US |
| Number | Date | Country | |
|---|---|---|---|
| 60743511 | Mar 2006 | US | |
| 60595559 | Jul 2005 | US | |
| 60595560 | Jul 2005 | US | |
| 60604348 | Aug 2004 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 11105527 | Apr 2005 | US |
| Child | 11457697 | US | |
| Parent | 11105490 | Apr 2005 | US |
| Child | 11105527 | US | |
| Parent | 11105524 | Apr 2005 | US |
| Child | 11105490 | US | |
| Parent | 10087856 | Mar 2002 | US |
| Child | 11105527 | Apr 2005 | US |
| Parent | 10087856 | Mar 2002 | US |
| Child | 11105490 | Apr 2005 | US |
| Parent | 10087856 | Mar 2002 | US |
| Child | 11105524 | Apr 2005 | US |
| Parent | 11457697 | US | |
| Child | 11105524 | Apr 2005 | US |
| Parent | 11381783 | May 2006 | US |
| Child | 11457697 | US | |
| Parent | 10864410 | Jun 2004 | US |
| Child | 11381783 | US | |
| Parent | 11207707 | Aug 2005 | US |
| Child | 10864410 | US | |
| Parent | 11079318 | Mar 2005 | US |
| Child | 11207707 | US | |
| Parent | 10382836 | Mar 2003 | US |
| Child | 11079318 | US | |
| Parent | 11125247 | May 2005 | US |
| Child | 11207707 | Aug 2005 | US |
| Parent | 10853126 | May 2004 | US |
| Child | 11125247 | US |
